Multi-professional framework for advanced clinical practice in England

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1 n England Multi-professional framework for New solutions are required to deliver healthcare to meet the changing needs of the population. This will need new ways of working, new roles and new behaviours.

2 The combined Professional Bodies and Royal Colleges representing the Health workforce published in October 2017 a Joint Professions statement - this stated their shared commitment to work together in the interests of the health of the nation to build effective multi-professional teams, building summative value by playing to the strengths of the professions within teams. uploads/2017/01/ _ncm_academy_joint_statement_action_plan.pdf Multi-professional work requires flexibility in attitude and behaviours and for professionals to value and respect the distinct contribution each professional makes. New ways of working and delivering healthcare requires employers to ensure that clinicians have the professional development they need to adapt to changing circumstances. Clinicians need to see there are appropriate career pathways open to them to enable them to expand their contribution to healthcare and their personal job satisfaction. Evidence consistently shows that multiprofessional team working delivers better outcomes for patients and more effective and satisfying work for clinicians. 2

3 Contents Foreword...4 Purpose...6 Context...7 Section 1: The capabilities for Definition...8 This section defines advanced clinical practice and its four pillars. 1.2 The capabilities for advanced clinical practice...8 This section outlines the capabilities within each of the four pillars of advanced clinical practice. Section 2: Key principles for the implementation of advanced clinical practice Planning the workforce and governance...11 This section sets out the key principles for the planning of the workforce. It provides the principles to support practitioners working at this level. It also sets out employers responsibilities. 2.2 Accountability...13 This section sets out the accountability requirements for the implementation of advanced clinical practice. 2.3 Education and development...15 This section establishes the developmental routes for advanced clinical practice. Conclusion...19 Glossary...19 Acknowledgments...20 Appendix 1: List of Contributors...21 Appendix 2: Resources (websites and Documents...22 References

4 Foreword The National Health Service was conceived and designed to deliver universal healthcare to communities across England and continues to provide unrivalled access and outcomes of any health system internationally. At the heart of this model is the outstanding commitment, compassion and expertise of the staff that work within it. This multi-professional Advanced Clinical Practice (ACP) framework set out a new and bold vision in developing this critical workforce role in a consistent way to ensure safety, quality, and effectiveness. It has been developed for use across all settings including primary care, community care, acute, mental health and learning disabilities. This framework recognises that the health and care system rapidly evolves to deliver innovative models of care, health and care professionals have adapted, to meet the increasing demands of individuals, families and communities. In their report, Reshaping the Workforce i, the Nuffield Trust identified the many benefits advanced clinical practice brings to patients, practitioners and employers but recognised the lack of clarity around the advanced practitioner role. This framework provides the clarity required for good governance, enabling employers to develop, enhance and deploy advanced clinical practice within their organisations. For the first time in England this framework sets out an agreed definition for advanced clinical practice for all health and care professionals and articulates what it means for individual practitioners to practise at a higher level from that achieved on initial registration. The framework sets out the capabilities expected of practitioners working at advanced level across four pillars; and it describes the educational and support requirements. Finally; it provides employers with advice on planning and implementing advanced clinical practice, ensuring appropriate clinical and organisational governance arrangements are in place. National adoption of the framework will ensure a common understanding of advanced clinical practice and will support individuals, employers, commissioners, planners and educators in the transformation of services to improve patient experience and outcomes. The organisations that have contributed to this framework have given a clear commitment to advance this agenda and support the expansion of advanced clinical practice for the future of the NHS. Alongside this a great deal of individual hard work and commitment has been demonstrated by all those who have contributed to the development of this Framework. Their expertise, insight, judgement and tenacity has been invaluable in building and developing the consensus required in order to publish this framework. John Clark Director and Dean of Education and Quality Regional Chief Nurse Health Education England - South Mark Radford Director of Nursing Improvement NHS Improvement Co-Chair of Advanced Clinical Practice Steering Group Suzanne Rastrick Chief Allied Health Professions Officer NHS England 4

5 It has been a pleasure to have been invited by the Chief AHP Officer to co-chair the ACP steering group on behalf of the Allied Health Professions. I have been grateful for the support from Dr Sally Gosling, who has provided significant contributions to this work, in her capacity as Chair of the Health and Care Professions Education Leads group. The framework offers a positive opportunity to harmonise advanced clinical practice across the diversity of roles, settings and sectors in which Allied Health Professionals practise. It should enable and strengthen support for advanced clinical practice development across the nonmedical workforce, thereby enhancing experience and outcomes for patients and progressing new models of care. Charlotte Beardmore Co-Chair of Advanced Clinical Practice Steering Group Health & Care Professions Education Leads Group (HCPEL) As the knowledge, skills and competencies of our workforce develop to meet the needs of patients and their families, it is right that we recognise this higher level practice. The Advanced Clinical Practice Framework provides this recognition for all healthcare practitioners to deliver outstanding care in any setting. The creation of this framework has been one of co-production with partners from practice, patients, higher education, professional bodies and the Arms Length Bodies. It has been a great privilege to share in this journey and ensure this framework is published. John Clark Director and Dean of Education and Quality Regional Chief Nurse Health Education England South As a former nurse consultant, I directly saw the patient and organisational benefits of advanced clinical practice delivered care. This new framework develops a common understanding across professions with agreed education and competency arrangements and it is the ideal platform to increase the use of this innovative NHS Workforce solution. It has been a great privilege to work with key stakeholders across professions to develop this ACP framework for the NHS. Mark Radford Director of Nursing Improvement NHS Improvement Co-Chair of Advanced Clinical Practice Steering Group The Advanced Clinical Practice Framework recognises the potential of health care professionals to enhance capacity, be innovative and deliver improved outcomes for patients. Suzanne Rastrick Chief Allied Health Professions Officer NHS England 5

6 Purpose This framework builds upon the definition of advanced clinical practice in England. This was developed and agreed by all stakeholders. It is designed to enable a consistent understanding of advanced clinical practice, building on work carried out previously across England, Scotland, Wales and Northern Ireland. The core capabilities for health and care professionals at the level of advanced clinical practice are articulated in this framework and these will apply across all advanced clinical practice roles, regardless of the health and care professional s setting, subject area and job role. Use of the word capabilities is intended to convey the extent to which health and care professionals working at the level of advanced clinical practice can adapt to change, generate new knowledge and apply it in different ways to formulate and problem solve within a context of complexity and uncertainty ii. This framework requires that health and care professionals working at the level of advanced clinical practice should have developed and can evidence the underpinning competencies applicable to the specialty or subject area, i.e. the knowledge, skills and behaviours relevant to the health and care professional s setting and job role. The core capabilities across the four pillars - clinical practice, leadership and management, education and research iii are then applied to these specialist competencies. These may be manifested/demonstrated in different ways depending on the profession, role, population group, setting and sector in which an individual is practising. For the purposes of this document hereafter core capabilities and specialist competencies will be referred to as the capabilities, as health and care professionals at the level of advanced clinical practice need to demonstrate both capability across the four pillars and competence. This framework sets the standard for the system with regards to the safe and effective requirements for advanced clinical practice, but allows for local context in regards to the implementation and application of principles. The framework has been written with the NHS in mind, however the fundamental principles and opportunity for workforce transformation are relevant across all sectors. Health Education England, NHS Improvement and NHS England intend the framework to be used as a standard for healthcare providers, service providers, employers, service leads 1, education providers and health and care professionals practising at, or aspiring to practise at, the level of advanced clinical practice. Transformation of the workforce will support the delivery of excellent care and health improvement to individuals and the public by optimising the way new and existing roles are developed. The key elements of the framework and a toolkit, which looks at the practical implementation of this approach, are available to individuals and the public on the Health Education England website ( 6 1 From herein this framework will refer to healthcare providers, service providers, employers and service leads as employers.

7 Context The NHS England Five Year Forward View (2014) iv and the NHS England Next Steps on the Five Year Forward View (2017) set out the current challenges experienced by the NHS, its possible future and choices to be made. It is recognised in England that the increase in demand for services is intensifying the pressure on the workforce. It is also acknowledged that there are several issues throughout England and at a regional and/or local level, which have resulted in some significant gaps in the workforce, as well as low retention and recruitment rates. The ability of the NHS to respond to these challenges has been affected by tighter financial constraints, growing workforce capacity issues and changes to working patterns. In addition, there have been significant concerns about the quality, safety and delivery of care in some settings (e.g. the issues raised in the Francis Report, 2013 vi ). Service providers have developed advanced clinical practice roles in response to some of these workforce and patient safety issues. The growth in advanced clinical practice roles has been accompanied by debate over how the level of advanced clinical practice should be defined and what core skills and capabilities are required, resulting in frameworks being developed locally and regionally over the past decade. These have offered similar, but varying, definitions of advanced clinical practice, rather than an agreed common definition which can be used across professional boundaries and in a range of contexts. Therefore, this framework provides the agreed definition of the level of advanced clinical practice to be applied to registered health and care professions in England. Key principles guide the planning and development of the workforce and its governance. The Five Year Forward View signals how the health service needs to change, arguing for a more engaged relationship with citizens and communities to promote well-being and prevent ill-health. This requires workforce transformation and a consistent approach to the development of new roles and new ways of working including advanced clinical practice as one of the many solutions i. A recent joint professions statement by the royal colleges and professional bodies representing the health workforce coordinated by the Academy of Medical Royal Colleges vii has supported and recognised this need and the professions have committed to work together to help create the environment to support effective team working and new ways of working and workforce development that impact on the quality of life of individuals, families and carers. This paves the way for different ways of working, using new models of care to achieve workforce transformation. A key driver for the implementation of advanced clinical practice is to enable practitioners to practise to their full potential and to optimise their contribution to meeting population and individuals, families and carers needs through different models of service delivery and multidisciplinary working. This document has been developed as a result of wide engagement and collaboration, with contributions from health and care professionals, employers, universities, professional bodies and patient and service user representatives. It draws on and consolidates existing frameworks relating to advanced clinical practice from across the UK and provides guidance and principles for current and future professionals working at the level of advanced clinical practice. 7

8 8 Section 1: The capabilities for 1.1 Definition The definition of advanced clinical practice was developed and agreed by all stakeholders is outlined below and some of the terminology has been updated to reflect more current language: Advanced clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making. This is underpinned by a master s level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence. Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people s experience and improve outcomes. This definition therefore requires that health and care professionals working at the level of advanced clinical practice will exercise autonomy and decision making in a context of complexity, uncertainty and varying levels of risk, holding accountability for decisions made. 1.2 Capabilities for advanced clinical practice in England All health and care professionals working at the level of advanced clinical practice should have developed their skills and knowledge to the standard outlined in this framework; the capabilities are common across this level of practice enabling standardisation. The four pillars iii that underpin this practice are: 1. Clinical Practice 2. Leadership and Management 3. Education 4. Research The language used to describe the capabilities is deliberately mapped to level 7 taxonomy to support and make clear the expectation that people working at this level are required to operate at master s level i.e. to have the ability to make sound judgements in the absence of full information and to manage varying levels of risk when there is complex, competing or ambiguous information or uncertainty. This framework acknowledges that the developmental pathway towards delivering advanced clinical practice may be different for individual practitioners. Health and care practitioners will demonstrate the capabilities in different ways, depending upon the nature of their scope and context of their practice, role and profession. It recognises there are many ways to gain and develop advanced practice capabilities, for further details please see the Education and development section. Listed below are the capabilities for health and care professionals working at the level of advanced clinical practice. The capabilities apply to all models of advanced clinical practice across sectors, specialties and professions and can be applied in either uni-professional or multiprofessional models of care provision. 1. Clinical Practice Health and care professionals working at the level of advanced clinical practice should be able to: 1.1 Practise in compliance with their respective code of professional conduct and within their scope of practice, being responsible and accountable for their decisions, actions and omissions at this level of practice. 1.2 Demonstrate a critical understanding of their broadened level of responsibility and autonomy and the limits of own competence and professional scope of practice, including when working with complexity, risk, uncertainty and incomplete information. 1.3 Act on professional judgement about when to seek help, demonstrating critical reflection on own practice, self-awareness, emotional intelligence, and openness to change. 1.4 Work in partnership with individuals, families and carers, using a range of assessment methods as appropriate (e.g. of history-taking; holistic assessment; identifying risk factors; mental health 2 The capabilities have been mapped to the Framework for Higher Education Qualifications FHEQ (2008) Qualifications Assurance Agency for Higher Education (QAA) level 7 descriptors relevant for master s level education (see

9 assessments; requesting, undertaking and/or interpreting diagnostic tests; and conducting health needs assessments). 1.5 Demonstrate effective communication skills, supporting people in making decisions, planning care or seeking to make positive changes, using Health Education England s framework to promote person-centred approaches in health and care viii. 1.6 Use expertise and decision-making skills to inform clinical reasoning approaches when dealing with differentiated and undifferentiated individual presentations and complex situations, synthesising information from multiple sources to make appropriate, evidence-based judgements and/or diagnoses. 1.7 Initiate, evaluate and modify a range of interventions which may include prescribing medicines, therapies, life style advice and care. 1.8 Exercise professional judgement to manage risk appropriately, especially where there may be complex and unpredictable events and supporting teams to do likewise to ensure safety of individuals, families and carers. 1.9 Work collaboratively with an appropriate range of multi-agency and inter-professional resources, developing, maintaining and evaluating links to manage risk and issues across organisations and settings Act as a clinical role model/advocate for developing and delivering care that is responsive to changing requirements, informed by an understanding of local population health needs, agencies and networks Evidence the underpinning subject-specific competencies i.e. knowledge, skills and behaviours relevant to the role setting and scope, and demonstrate application of the capabilities to these, in an approach that is appropriate to the individual role, setting and scope. 2. Leadership and Management Health and care professionals working at the level of advanced clinical practice should be able to: 2.1 Pro-actively initiate and develop effective relationships, fostering clarity of roles within teams, to encourage productive working. 2.2 Role model the values of their organisation/place of work, demonstrating a person-centred approach to service delivery and development. 2.3 Evaluate own practice, and participate in multi-disciplinary service and team evaluation, demonstrating the impact of advanced clinical practice on service function and effectiveness, and quality (i.e. outcomes of care, experience and safety). 2.4 Actively engage in peer review to inform own and other s practice, formulating and implementing strategies to act on learning and make improvements. 2.5 Lead new practice and service redesign solutions in response to feedback, evaluation and need, working across boundaries and broadening sphere of influence. 2.6 Actively seek feedback and involvement from individuals, families, carers, communities and colleagues in the co-production of service improvements. 2.7 Critically apply advanced clinical expertise in appropriate faciliatory ways to provide consultancy across professional and service boundaries, influencing clinical practice to enhance quality, reduce unwarranted variation and promote the sharing and adoption of best practice. 2.8 Demonstrate team leadership, resilience and determination, managing situations that are unfamiliar, complex or unpredictable and seeking to build confidence in others. 2.9 Continually develop practice in response to changing population health need, engaging in horizon scanning for future developments (e.g. impacts of genomics, new treatments and changing social challenges). 9

10 2.10 Demonstrate receptiveness to challenge and preparedness to constructively challenge others, escalating concerns that affect individuals, families, carers, communities and colleagues safety and well-being when necessary Negotiate an individual scope of practice within legal, ethical, professional and organisational policies, governance and procedures, with a focus on managing risk and upholding safety. 3. Education Health and care professionals working at the level of advanced clinical practice should be able to: 3.1 Critically assess and address own learning needs, negotiating a personal development plan that reflects the breadth of ongoing professional development across the four pillars of advanced clinical practice. 3.2 Engage in self-directed learning, critically reflecting to maximise clinical skills and knowledge, as well as own potential to lead and develop both care and services. 3.3 Engage with, appraise and respond to individuals motivation, development stage and capacity, working collaboratively to support health literacy and empower individuals to participate in decisions about their care and to maximise their health and well-being. 3.4 Advocate for and contribute to a culture of organisational learning to inspire future and existing staff. 3.5 Facilitate collaboration of the wider team and support peer review processes to identify individual and team learning. 3.6 Identify further developmental needs for the individual and the wider team and supporting them to address these. 3.7 Supporting the wider team to build capacity and capability through work-based and interprofessional learning, and the application of learning to practice 3.8 Act as a role model, educator, supervisor, coach and mentor, seeking to instill and develop the confidence of others. 4. Research Health and care professionals working at the level of advanced clinical practice should be able to: 4.1 Critically engage in research activity, adhering to good research practice guidance, so that evidencebased strategies are developed and applied to enhance quality, safety, productivity and value for money. 4.2 Evaluate and audit own and others clinical practice, selecting and applying valid, reliable methods, then acting on the findings. 4.3 Critically appraise and synthesise the outcome of relevant research, evaluation and audit, using the results to underpin own practice and to inform that of others. 4.4 Take a critical approach to identify gaps in the evidence base and its application to practice, alerting appropriate individuals and organisations to these and how they might be addressed in a safe and pragmatic way. 4.5 Actively identify potential need for further research to strengthen evidence for best practice. This may involve acting as an educator, leader, innovator and contributor to research activity ix and/or seeking out and applying for research funding. 4.6 Develop and implement robust governance systems and systematic documentation processes, keeping the need for modifications under critical review. 4.7 Disseminate best practice research findings and quality improvement projects through appropriate media and fora (e.g. presentations and peer review research publications). 4.8 Facilitate collaborative links between clinical practice and research through proactive engagement, networking with academic, clinical and other active researchers 10

11 Section 2: Key principles for the implementation of advanced clinical practice 2.1 Planning the workforce and governance How to ensure the right people, with the right skills, are in the right place at the right time is a key priority to enable delivery of sustainable health and care services. This framework is relevant for any service looking to transform its workforce to meet the needs of the population through the employment of advanced clinical practice roles. How these are integrated into service delivery and team structures for a sustainable, consistent approach to the advanced clinical practice workforce development are presented as broad principles. This is so as to embrace the multiple settings and roles at this level and local context. In this section, both planning and governance of this workforce are addressed. The governance of advanced clinical practice roles is vital to their success. Good governance involves inclusive, participative decision making with clear lines of accountability and responsibility. Policies and processes need to be in place and must include the evaluation of effectiveness, impact, ongoing sustainability and responsiveness. Organisations must ensure that robust governance arrangements surrounding all types and levels of practice, are in place prior to the establishment of new roles, and these must be enhanced and strengthened for existing ones. As stated in the definition at the beginning of this framework, advanced clinical practice refers to a level of practice. Currently many titles are used for health and care professionals who work as this level such as Advanced Clinical Practitioner, Advanced Nurse Practitioner and Advanced Practice Therapeutic Radiographer. It is important to note that some professionals have been given the term advanced in their role descriptor, but may not working at this level for various reasons. This may mean that employers need to review their workforce in order to make sure that there is no misunderstanding by the public and the multidisciplinary team. Where needed, such professionals should be supported, developed and facilitated to work across all four pillars. Governance arrangements must be in place to consider these cases. Please see case examples - our-workforce/advanced-clinical-practice/case- studies. In order to embed advanced clinical practice and ensure its sustainability, it is necessary that the organisational governance and infrastructure arrangements include consideration of the following aspects of service transition: Practice governance and service user safety requirements Adherence to legal and regulatory frameworks Support systems and infrastructure for delegated roles (e.g. requesting diagnostic tests, administering medicines) Professional and managerial pathways of accountability Continued assessment against, and progression through, the capabilities identified within this framework Location of advanced clinical practice within a career framework that supports recruitment and retention, and succession planning to support workforce development Regular constructive clinical supervision that enables reflective practice together with robust annual appraisal. The process of planning and thinking through these elements for advanced clinical practice roles in the workforce should result in the development of a business case that includes the above information and the resources required. The financial aspects should not be considered in isolation. Consideration must also be given to the ongoing support and structures that may be required to facilitate education, ongoing development, assessment and supervision (see the Education and development section). A risk analysis and options appraisal, as well as an evaluation of the impact and effectiveness of existing and new roles should be included (see the toolkit for further tools and examples). 11

12 Key principles for planning the workforce and governance: In identifying the need for such roles and their potential impact, employers need to: 1. Consider where advanced clinical practice roles can best be placed within health and care pathways to maximise their impact Historically there have been many drivers for the introduction of the level of advanced clinical practice: clinical, operational, financial and professional. However, primary consideration must be given to where this level of practice would be best placed for greatest impact in health and care pathways. This may mean that those working in advanced clinical practice might operate outside traditional service delivery boundaries and potentially, traditional professional boundaries. The intention should be to move towards developing and planning the workforce to meet local population needs. Therefore, at the local area level, organisations should be working to generate a sustainable supply of health and care workforces who are able to work more flexibly across these boundaries. 2 Define a clear purpose and objectives for advanced clinical practice roles. The level of advanced clinical practice typically exists across professional boundaries within multi-professional teams. Planning must not be done in isolation, local consideration must be given to workforce supply, existing roles and support for development. In addition, attention must be paid to the starting points for different professions relative to their core training, as well as to their duties and responsibilities. The capabilities which reflect the area of work or specialty will be required to be clearly defined. Clinicians and service managers should be involved in planning the workforce together. Such planning should focus on the wider team, thinking about the value of the role and its purpose and objectives. Practitioners must be working to national standards, where these exist. 3. Consider and evaluate the impact of advanced clinical practice roles on service user experience and outcomes and on service delivery and improvement objectives. Patient/service user and public involvement in understanding these roles, their functions and boundaries as part of the wider health and care teams, is essential and must be built into this process. The importance of ensuring continuous improvement in the quality of care to individuals is widely recognised. It is therefore necessary to measure the impact of the activities of all staff, with a particular focus on new roles added to the workforce. The development and utilisation of robust evaluation methods is essential. In addition, evidence demonstrating value for money and good quality of care may be required to influence senior management teams to support the introduction of new roles. This will include how the organisation or employer should quality assure itself to ensure the safety and effectiveness of the advanced clinical practice roles. For example, by using methods for monitoring and evaluating both effectiveness and impact such as, the monitoring of complaints, incidents and patient/service user outcomes and feedback. This is an essential part of governance, i.e. the observation and evaluation of intended and unintended consequences. There are specific questions employers need to address in considering advanced clinical practice roles and to ensure good governance of those roles What objective outcomes are expected from the advanced clinical practice role? When will these outcomes be achieved and how will these be measured pre and post implementation? What risks and unintended consequences might there be to the introduction of this role and how may they be mitigated against? What resources and support are required for role development and succession planning? Is workforce optimised to ensure clinical and financial benefits are maximised? How will on-going competence and capability be reviewed and enabled? 12

13 What reporting and line management structure will be in place? What processes will identify gaps in performance and/ or shortfalls in implementation and how will these be addressed? Has a quality assurance model been considered to measure this e.g. CQC 5 key lines of enquiry which will support inspection. Thinking through these questions and finding answers will then guide governance structures and policy development but also evaluation against expected and unexpected outcomes. 4. Ensure clarity about the service area the individuals will work within Understanding the level of advanced clinical practice relative to the wider team, requires the roles of all team members, i.e. those above, below and surrounding this level, to be understood. Multi-professional engagement in this work is essential to build trust, understanding, supervision and support (see the Education and development section for more information on supervision). Those working in an advanced clinical practice role will need to negotiate their individual scope of practice with service managers and the rest of the team. The wider team needs to understand the level of accountability of those in this role. To achieve these objectives there needs to be clarity and understanding as well as a proactive culture of working in partnership. By advancing the level of practice of some staff, the people in the grades below may need some development to increase their skills and knowledge as the expectation of their roles develops too. Staff in the grades above may need some support to potentially change some aspects of their role and potentially start doing some work differently. This must be understood, supported and widely communicated. Employers also need to consider impact planning and the evaluation of the team into which the new role is introduced, and those it may impact on outside this team, reflecting on the implications for the skills mix and any changes that might be needed. This process may then enable career and succession planning opportunities. 5. Ensure clear and unambiguous support for the role from the organisation/ employer at all levels The employer must recognise the responsibilities and capabilities of someone working in these roles. This must be reflected and supported at a local and organisational level. The support must be wider than educational, the voice of the those working in an advanced clinical practice role must be heard via existing or new governance and reporting structures. The board level directors, the clinical leads for the profession and managers must be aware of, understand and recognise the value of, advanced clinical practice roles. This must be cited in the governance arrangements, so that there are clear lines of professional and managerial accountability up to board level. In addition, the employer must be aware that certain skills, e.g. prescribing, are only legally allowed for certain professions, and that this does not preclude all professions from working in an advanced clinical practice role. 6. Develop a succession plan for future workforce. This should be actively supported for service sustainability, succession planning and staff retention. Clarity in the above principles will enable a clear pipeline to be developed and will support retention. 2.2 Accountability Health and care professionals working in advanced clinical practice roles are encouraged to work to their full potential to optimise the benefits that can be gained from new models of care. Therefore, individual and organisational governance need to be robust and within legal, regulatory and professional frameworks, as there is a possibility that professionals taking on new roles and responsibilities could put people at risk. This could be caused by lack of competence to carry out duties safely or effectively, or where adequate safeguards are not in place, if these roles are not properly supported. This section examines these elements of governance which must be in place for the advanced clinical practice role. For the purpose of this document and the point in time at which it has been formulated, this framework applies to those who have statutory registration. In order to offer 13

14 clarity to the system, this work has been formulated with the regulated workforce in in mind. It is understood that there are some professions that are being considered for statutory regulation and therefore are not registered at this time. Not being registered does not preclude these professional groups from working at this level but employers and employees must understand the implications and have an appropriate approach to this through safe and effective governance. The development of advanced clinical practice roles requires that: 1. Individual practitioners, as registered professionals, continue to hold professional responsibility and accountability for their practice. Work by the Commission for Healthcare Regulatory Excellence (2009) xi, now the Professional Standards Authority, emphasised that the activities undertaken by professionals at a level of advanced clinical practice do not lie beyond the scope of existing regulation, unless the nature of their practice changes to such a significant extent that their sphere of practice is fundamentally different from that at initial registration. Practitioners working in advanced clinical practice roles must be aware of their own limitations and through this, recognise the parameters of their scope of practice. It is proposed that advanced clinical practice roles should reflect a set of responsibilities and capabilities which act as an indicator of a specific stage on the career development ladder. In addition, such practitioners will always be accountable to their original regulatory body, whatever the level or context of their practice. This has been reflected in the capabilities. 2. Employers recognise and accept potential new responsibilities and greater accountability in relation to governance and support for these roles and associated level of practice. Governance has been mentioned in the key principles for planning the workforce and governance. It is also cited in the capabilities. It applies to all registrants and is articulated within respective professional codes of practice. Employers carry responsibility and vicarious liability for practitioners, and must be responsible for ensuring that all advanced clinical practice roles, both those that are existing or those of the future, do not compromise safety. Policies and processes may need to be modified to reflect this. Without this, there is a risk of unconscious incompetence xii, which may compromise safe person-centred care, as well as the reputation of advanced clinical practice. 3. Professional support arrangements, which recognise the nature of the role and the responsibilities involved must be explicit and developed. Good governance regarding new role development and implementation must be based on consistent expectations and understanding of the level of practice required to deliver the service and assure safe quality standards of practice for service users. This is best achieved through the benchmarking of such posts against: agreed standards in England, best practice and the capabilities under the four pillars. Strategies such as supervision, mentorship, good record-keeping, ongoing self-assessment and development are an essential element of demonstrating accountability within practice. Existing professional support mechanisms may not be sufficient and may need to be reviewed. These processes and strategies should be complemented by clear lines of professional responsibility and linemanagement and regular independent clinical reviews. Management lines of accountability may need strengthening as often staff will have a line manager separate to their team and may perhaps work across a number of teams which may add complexity and competing pressures. This must be understood and managed. Appraisal processes may need strengthening. These processes will need to be completed in collaboration with the line manager and an appropriately qualified clinical lead. Appraisal may use evidence or feedback; clinical audit data; outcomes and issues review: productivity measures; 360 degree feedback and service user feedback. This approach provides the most effective means of controlling risks to a patient/service user s safety from an individual professional s practice and provides a proportionate response. 14

15 4. Employers must ensure regular review and supervision is carried out by those who are appropriately qualified to do so. Governance arrangements must also ensure that those who support and review practice are also developed, facilitated and supported to carry out this role. 2.3 Education and development This section outlines the principles to support the development of the workforce to work at the level of advanced clinical practice. The document recognises and respects that there are many ways to gain and develop these capabilities. It aims to ensure that there are robust and clear routes to evidencing achievement of the capabilities. Educators and employers are therefore challenged to enable capability and competence, offering an environment and a process that allows practitioners to develop abilities that are sustainable for changability, improvability and responsiveness. ii Principles for education and development At an advanced clinical practice level the attainment of both competence and capability are important: It is essential that practitioners are developed to be clinically competent within their specialty, sector and setting. Capability development is also essential: this requires practitioners to be able to recognise what level of competence is required within any given situation and apply this successfully, recognising the limits of their competence. Capability also requires the practitioner to have the ability to extend these limits when required and flexibly adapt to unfamiliar professional environments. Local adaptation of this guidance is important to ensure workforce development is matched to local population needs, however the capabilities are deliberately stated in order to support a common understanding and expectation of this level of practice, in order to facilitate the development and mobility of this workforce at scale. In order to meet the diverse and ever-changing workforce needs, it is essential that an outcome driven approach to developing the workforce is utilised, using the capabilities to ensure underpinning consistency and rigor. Therefore, the focus must be on the outcome, i.e. of the capabilities being met at the required level, as opposed to the developmental input or the educational process undertaken. Education progression routes need to enable practitioners to develop and demonstrate the capabilities, recognising that this can be achieved in multiple ways, dependent upon sector, profession, setting, role and service need. The flow chart in the Development routes diagram (page 16-17) shows the educational routes possible to develop both clinical competence and capability. The development of health and care professionals to enable them to operate at the level of advanced clinical practice, requires three elements within the workplace: development of competence and capability supervision and support in the work place assessment of competence and capability Development of competence and capability Practitioners and employers will need to work collaboratively to identify individual learning needs and determine the most effective route to meet these. It is essential to recognise that each profession will begin from a different starting point in their development of advanced level skills. Employers are encouraged to support practitioners to identify personal learning plans, help and meet their learning needs by supporting the: clear articulation of the role and scope to be undertaken understanding of the availability of existing speciality specific national clinical competencies or support to develop these with the clinical team mapping of previous education or experience against the four pillars to decide whether a practitioner s existing qualifications cover the relevant capabilities required for the level of advanced clinical practice in the health and care professional s setting, subject area and job role. This may enable the individual to evidence some of the required capabilities through a portfolio route or as APL/APEL. 15

16 Multi-professional framework for appraisal of existing educational programmes content, approach and structure to determine match to individual requirements agreement of an appropriate educational approach e.g. programme of assessed work based learning and/or an academic programme understanding of funding routes e.g. apprenticeship, local funding arrangement etc. agreement of the required work based assessments to evidence sustained attainment of the agreed capabilities in practice support of a named, trained educational supervisor, who is a specialist within the clinical area, to support the work based learning and assessment and sign off for the capabilities/portfolio. The accreditation or recognition of relevant prior learning or prior experiential learning (APL/ APEL) process is integral to ensure health and care professionals existing qualifications and experiential learning are recognised as appropriate. New models of evidencing RPL and equivalence are being explored. Individuals and healthcare providers may utilise a combination of approaches e.g. work based learning, simulation or e-learning to ensure that professionals developing a portfolio to evidence advanced clinical practice get full exposure to the appropriate levels of learning. All routes are important as some health and care professionals aspiring to work in an advanced clinical practice role may have completed alternative qualifications at master s level, particularly in health and care professions that require a master s level award for registration. Clinical training must acknowledge the importance of time and experience to build confidence in decision making and the management of risk. It is important to note that having a master s degree does not grant the practitioner advanced clinical practitioner status. Evidenced achievement of the capabilities, employer support and a clear funded role to move into are all essential components. Development routes The following flow chart provides guidance on the possible ways of evidencing the capabilities within the four pillars of advanced clinical practice 1. You are registered with the appropriate UK statutory regulatory body for your profession? Yes 2. Do you have a master s level award (Level 7)? E.g. postgraduate certificate, postgraduate diploma or full master s degree? And Were all 4 pillars of the advanced clinical practice capabilities covered, and assessed in practice, as part of your Level Yes Pathway to Evidence level of Advanced Clinical Practice No No Not fully Advanced Level of Clinical Practice has been evidenced A. You do not meet the essential requirements for an advanced clinical practice role and will need to apply for registration with the appropriate UK statutory regulatory body. B. You will need to undertake a formal accredited development programme, such as a master s level programme at a University or a formal accredited work-based programme with content relevant to the capabilities for advanced clinical practice. C. If your master s level award (level 7) did not cover one or more of capabilities in each of the 4 pillars of advanced clinical practice, you will need to undertake a formal process recognising prior learning and experience to identify and address gaps in your capabilities. This should be assessed by your employer, supervisor and an educational assessor and additional modules undertaken at master s level award for advanced clinical practice may be required that include work based learning, assessment and clinical supervision whilst learning. This should be used to create a portfolio of evidence or work based learning that demonstrates your advanced clinical practice specific to your area of practice. Or Submit a portfolio of evidence or work based learning showing how you meet all the required capabilities for working at master s level. This must be assessed by your employer and an educator (with experience of assessing advanced clinical practice) through a process of accrediting or recognising prior formal or informal learning and experience. 3. You have evidence that you meet all of the capabilities and therefore meet the requirements to undertake an advanced clinical practice role. Maintain a portfolio of ongoing evidence or work based learning that will be reviewed as part of the annual appraisal

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